242502 02/24/15 CITY OF CARMEL, INDIANA VENDOR: 368374
a;
i' ONE CIVIC SQUARE RITA COLLINS CHECK AMOUNT: $***....300.00*
CARMEL, INDIANA 46032 4389 ELKHORN DRIVE CHECK NUMBER: 242502
WESTFIELD IN 46062 CHECK DATE: 02/24/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 300.00 HSA
City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below has elected Plan A for 2015 and is eligible for a bi-
annual contribution to his or her HSA account, as authorized by Resolution BPW-10-03-12-02.
Please return check to Human Resources for further processing_
Plan Participant/Payee:
Rita Collins
4389 Elkhorn Drive
Westfield, IN 46062
Amount: $300.00
Fund: Medical Escrow Fund (301)
Date: February 23, 2015
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Forth No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Rita Collins Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02/23/15 02.23.15 Annual-HQalth Sm ings Account
Contribution $300.00
Total
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accor-
dance with IC 5-11-10-1.6.
, 20
Clerk-Treasurer
VOUCHER24,1�WARRANT NO.
ALLOWED 20
IN SUM OF $
4389 Elkhorn Drive
Westfield, IN 46062
%10000
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s),
or bill(s) is (are) true and correct and that
23.15 300.00 the materials or services itemized thereon
for which charge is made were ordered and
received except
�L 20
Signature��
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund